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Supervisor, Utilization Management (Concurrent Review)
Job Description
Department(s): Utilization Management (Concurrent Review)
Reports to: Manager Utilization Management
FLSA status: Non-Exempt
Salary Grade: N – $95,000 – $155,078
Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Thursday, November 16, 2023 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.
About CalOptima Health
CalOptima Health is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — “Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. If you’re looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima Health.
About the Position
The Supervisor Utilization Management (Concurrent Review) will monitor and oversee daily operational department work activities to ensure that service standards are met. The incumbent will make recommendations regarding assignments based on the assessment of workload and is a resource to the Concurrent Review staff regarding CalOptima Health’s policies and procedures and regulatory requirements governing authorization processing. The incumbent will provide ongoing monitoring and development of staff.
Duties & Responsibilities:
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Trains, audits and supervises all Concurrent Review employees’ adherence to the Medi-Cal and Medicare processing guidelines, CalOptima Health and hospital policies, procedures and processes.
• Identifies, develops and implements new learning opportunities for staff (e.g., new desktop procedures).
• Conducts performance evaluations and provides feedback to staff.
• Participates in the hiring process and selection.
• Assists in the monitoring of appropriate application of eligible benefit verification, evidence-based review of guidelines to determine medical necessity with appropriate routing and timely completion of authorization requests.
• Makes assignments based on authorization priority, overall workload, staffing and review of timeliness reports.
• Attends Concurrent Review processing when needed to ensure department turn-around times are met and maintained.
• Assists the Manager Utilization Management in all areas of the department, as needed, to ensure departmental and organizational goals are met.
• Serves as subject matter expert (SME) and acts as a resource to departmental staff, internal departments and affiliated health networks regarding authorization rules and processes.
• Provides coverage for other units within Utilization Management.
• Reviews work procedures and processes; evaluates and recommends necessary modifications for increased effectiveness and efficiency.
• Conducts Concurrent Review presentations as assigned.
• Completes other projects and duties as assigned.
Experience & Education:
• Associates degree in Nursing (ADN), Bachelor’s degree in Nursing (BSN) or Licensed Vocational Nursing (LVN) diploma required.
• Current and unrestricted Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license to practice in the State of California required.
• 3 years of clinical nursing experience or utilization management experience required.
• 2 years of supervisory or lead experience in managed care/utilization management required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Physical Demands and Work Environment:
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Physical demands: While performing duties of job, employee may be required to move about the organization and to travel to offsite locations. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes or laptop case, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings, face-to-face interaction and while presenting.
• Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures.
About our Benefits & Wellness options:
At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.
CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.
CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.
Job Location: Orange, California
Position Type:
To apply, visit https://apptrkr.com/4758791
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